Medicine in quest of a service population: Spain, 19th and 20th centuries

Abstracts

Se presenta el conjunto de trabajos que constituyen este número. Bajos distintos aspectos, en todos ellos se explora el proceso de constitución de la medicina en 'profesión de servicio' en el contexto de la formación histórica española, metropolitana y colonial, entre los siglos XIX y XX, fijándose en el modo cómo alcanza relaciones permanentes y rutinarias con un público. Los distintos estudios abordan aspectos en general poco estudiados, como el mundo de la medicina militar, la colonización española en Marruecos, las campañas sanitarias y la conjunción de la medicina con la previsión social, se basan en un amplio elenco de fuentes originales y contribuyen a esclarecer los procesos ideológicos, institucionales y profesionales que configuran la medicina de hoy.

público; profesión; especialización; campañas sanitarias; España

DOSSIÊ PERSUASIÓN Y DOMINIO: MEDICINA Y PÚBLICO EN ESPAÑA (SIGLOS XIX Y XX)

Medicine in quest of a service population: Spain, 19^th and 20^th centuries

Esteban Rodríguez Ocaña

Universidad de Granada Facultad de Medicina, Depto. Q. P. Historia de la Ciencia Granada, España [e-mail]

ABSTRACT

Approaching from various angles, the articles in this dossier explore the process by which medicine became a 'service profession' within the context of the historical formation of both metropolitan and colonial Spain between the nineteenth and twentieth centuries – that is, how ongoing, routine relations with a given public came to be established. The articles address facets that by and large have not been the object of much study, such as the world of military medicine, Spanish colonialism in Morocco, public health campaigns, and the intersection of medicine and forms of social security. Based on a broad gamut of original sources, these studies offer a contribution to our understanding of the ideological, institutional, and professional processes that have helped shape today's medicine.

Keywords: service population; profession; specialization; public health campaigns; Spain.

According to the classical formulation of Freidson, contemporary Western medicine can be considered a profession of service, shaped by an extremely long historical and cultural process. The collection of articles that makes the present issue of História, Ciências, Saúde – Manguinhos wishes to contribute to the study of this process by means of a little-used approach, focusing on the relationships between medical professionals and the public, an essential element in this modality of service.

In the case of Spain, this professional model was produced by decisive state intervention. While this intervention had favored Galenic medicine (i.e. the scientific medicine of the time) since the Middle Ages and professionals were entrusted with permanent functions in the public domain (García Ballester, 2001), there was a marked strengthening of this predilection in the 18^th century, with the incorporation of new scientific styles that were emphatically separated from ancient traditions. Thus, administrative intervention in the regulation of medical practice, e.g., the Real Tribunal del Protomedicato (López Terrada and Martínez Vidal, eds., 1996; Campos Díez, 1999), brought to an end the traditional craft "open model" that had historically characterized the training of physicians and other healthcare professionals. This trend was consolidated under the District Medical Academy system in the following century, whose obligations included ensuring that professionals under their jurisdiction had the appropriate qualifications. In addition, beginning with surgeons, posts were made available in the Navy and then the Army for professionals trained at new centers (Colleges of Surgery) associated to hospitals (Astrain Gallart, 1996; Massons, 2003). These developments added to the traditional and relatively uniform coverage offered in most parts of the Peninsula in the mid-18^th century by municipal physicians, surgeons and bloodletters (Ortiz et al. 1995). The original justification of this policy was its utility, considering the obligatory availability of scientific-medical care to be positive for the well-being of the population and, crucially, of the Absolutist State.

At the start of the Carlist War on the death of Fernando VII, the Military Health Corps was formally established to offer permanent availability of medical-surgical care to soldiers and, at garrisons, to their families (Massons, 1994). The training and development of this Corps has received little attention to date, apart from some commemorative accounts. There has been no investigation of the interdependence between this process and the changing colonial situation in Spain, i.e., the remains of the Empire in the Caribbean and Pacific and the new adventures in Africa. This issue is addressed by Martínez Antonio in the first study of this collection, which emphasizes the importance that should be given to historical evaluation of military health resources in Spanish daily life, in terms of public health and healthcare, as a permanent branch of the health system that has hitherto been ignored.

The army had a primordial role in the colonizing experience of the so-called Morocco Protectorate, which lasted from 1912 to 1956 and resulted from accords reached with England and France. In international histiography, the history of colonialism has come to take account of local resistance, reinterpretations, and influences, encouraging comparative and cultural approaches ("postcolonial perspective"). There are numerous studies of colonial medical practice within the project of metropolitan or imperial domination and as an instrument in the construction of cultural and social identities (cf. Anderson, 1992; Arnold, 1993; Worboys; Palladino, 1993; Eckart, 1997; Marks, 1997; Stern, 1999; Sutphen, Andrews eds., 2003). From this perspective, Molero-Mesa reveals in considerable detail the problematic situation brought about by the clash between different medical cultures, with the medicine of the occupying forces itself used as a colonizing resource, i.e., as an instrument for devaluing the culture of subjugated peoples. He describes the resources devoted to this campaign and the effects on both the Muslims and the Spaniards.

Although the place of scientific-medical knowledge and its practices in the colonial adventure have been reviewed, feminist studies have criticized the lack of a gender perspective in colonial analyses (Lewis, 1996), highlighting the complicated situation of Western women in the colonial setting (Blunt; Rose, eds., 1994). Jiménez-Lucena addresses this issue by contributing with a study on gender aspects in relation to both the colonialists and the colonized, in which medicine has played and continues to play an important shaping role.

The colonial situation exaggerates certain aspects of the medicine-public relationship in the ceding of authority (in the sense of coercive power) to the professionals, especially but not exclusively among the autochthonous population. In the military setting as well, healthcare professionals, as officers, had power over lower ranks, particularly over enlisted soldiers. This was also the case in the context of asylums or charitable work, where patients had no right to healthcare, which was received on a grace-and-favor basis. Hence, analysis of the colonial problematic, especially from a post-colonial perspective, contributes to clarifying our knowledge of the dynamics of social life.

Beyond the military ambit, in a society living through changes imposed by industrialization and the rise of the bourgeoisie, professional practice developed in a plural context. Its relationship with the public was subject to different determining factors, starting with the economic one. The more or less liberal bourgeois society provided the framework for the development and crisis of the beneficence system. In the triple organizational structure laid out in the corresponding legislation (1822, 1849), the municipalities were responsible for establishing systems to offer permanent medical care for the needy as well as health prevention and surveillance measures ("beneficencia municipal"). The efficacy and size of these facilities evidently varied according to the size of towns and local social-political vicissitudes (Caraza, 1991, 1992; Valenzuela, 1994 and 1996; Esteban de Vega, ed., 1997). For their part, Provincial Councils were obliged to provide hospital care for acute diseases and treatment of some types of chronic disease, especially mental illness. In all cases, the population covered had to be included in the Census of the Poor. Professionals were constantly urged to maintain and update this census throughout its existence, since public healthcare served as a base for the creation and development of commercial medicine. Moreover, the beneficent system, with all its limitations, guaranteed the demand for healthcare from wide sections of the population, thereby facilitating the spread of medical specialties.

Indeed, there was an increasingly rapid growth of university-based professional medicine as the 20th century approached, with a diversification in training and job offers that generated autonomous and monopolistic professional segments. As pointed out by Weisz (2005), this diversification process took place thanks to various factors, conjugated by the interests of individuals and institutions involved. Within the sequence of historic realities that gave rise to the appearance of specialties, a critical stage corresponds to the availability of care centers offering practices that would eventually form the nucleus of an independent medical field. In Spain, the beneficent facilities fulfilled this function. This is made clear in studies on the development of Radiotherapy (Medina Doménech, 1996), Public Health (Marset Campos; Rodríguez Ocaña; Sáez Gómez, 1998; Rodríguez Ocaña, 2002) and Paediatrics-Childcare (Rodríguez Ocaña, 1999). When the beneficent system was replaced by social insurance (the first health insurance was for work accidents in 1900 followed by maternity in 1931), these new centers in turn acted as facilitators of the specialization process (Seguros, 1988; Historia, 1990). This process, which has continued to the present day, was sustained by the development of Health Insurance Hospitals in the 1950s (Huertas, 1994; Rodríguez Ocaña, 2001). The next four papers in this issue address the achievement of social legitimacy by specialties, in other words, the winning over of a loyal public.

The article by Rodríguez Ocaña and Perdiguero examines the process of replacement of the content and personnel related to childcare that took place in the 19th and 20th centuries, which eventually made the visit to the pediatrician a matter of routine. They focus on the ideological struggle that targeted "popular medicine" as an object of denigration and on the production of institutional facilities designed to conquer this new territory, traditionally managed by primary social networks. In line with the ideas of Apple (2002), they describe the scientific demarcation between the "child" and the "mother" that was produced in Spain and all industrialized countries (see studies cited in Rodríguez Ocaña, 2003).

The paper by Castejón et al. analyzes one of the new media that have been used to gain the loyalty of clients, i.e., the use of posters for health publicity. The spread of medicine as an active presence in the social body demands constant campaigns aimed at persuading the population. In fact, new preventive policies supported by the medical-social approach of the 20th century, with its emphasis on health education, became one of the main agents in the winning of scientific authority and social legitimacy for contemporary medicine. The democratization of the image is central to understanding the social repercussions of technological advances (García Fernández et al., 2000). At the beginning of the 20th century, the informal communication channels for science were books, pamphlets, magazines, educational talks, and posters, followed later by the cinema, radio and television. Castejón and colleagues center on publicity posters used for persuasion, stimulating adherence to behaviors related to a value system. The health poster, of which there were some examples in the 19th century, is clearly fruit of the mentality of the inter-war period and represents an important historical source. Thus, posters from Poland, Russia and Spain were the subject of conflicting analyses at the Science, Public Policy and Health in Europe Symposium held in Barcelona in 1998 (Löwy and Krige, eds., 2001).

The contribution by Porras addresses the participation of the social insurance system, which generated cover for new medical specialties at the same time as it was facing important social and employment challenges. A central element in the development of occupational medicine was social concern about work accidents. While the focus of Spanish legislation in 1900, 1922, and 1932 was on the legal and economic protection of accident victims, it also acted as a decisive stimulus for the generation of posts for physicians in industrial and health insurance companies. Moreover, it led to the creation of public facilities, first for healthcare and rehabilitation and then also for teaching purposes, which proved decisive in the shaping of this specialty (Menéndez Navarro, Rodríguez Ocaña, 2003). Influenced by both actuarial specialists and some medical sectors, employment legislation created a new scenario for the development of a specialty, i.e. the Institute for the Professional Re-education of the Work Disabled and its successors, the National Reeducation Institute and the Work Clinic of the National Insurance Institute. An analysis of their professionalizing contents is offered in the paper by Martínez Pérez, who underlines the connection between these new scenarios and the social problem of disability. His study significantly contributes to the growing body of inter-disciplinary studies on disability. In these last two studies, as in the previous one, we are shown a way of imposing medical action by its conversion into a condition for the receipt of other types of service (food or financial) for meeting basic needs.

BIBLIOGRAPHY

Submitted on Fabruary 2006.

Approved on April 2006.

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Publication Dates

• Publication in this collection
  10 Oct 2006
• Date of issue
  June 2006

History

• Received
  Feb 2006
• Accepted
  Apr 2006